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December 05, 2006

Tradeoffs are almost everywhere

Sidney Zion is famous for channeling his grief and rage at the death of his teenaged daughter in New York Hospital into changing how doctors are trained in the U.S.

But like almost everything in life, institutional reform faces tradeoffs. Reforms usually have their own risks and costs. (Not that I accept the New York story at face value. But it raises useful questions.)



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Dave Meleney

So... the hospitals have drastically reduced the physician oversight at night, in response to a law saying "no more 36 hour shifts". If this weren't so tragic...I'd think it was John Balushi on Saturday Night Live.

My parents 79 and 83 years old and the following line scares me..."He didn’t even have time, because of his patient load, to do more than skim the most recent chart entry to figure out what was going on—though, given the usual perfunctory nature of the ten to fifteen pages of chart notations, a more thorough reading might not have helped anyway."

If we suddenly have someone in serious medical condition, do I hire a nurse or medical student to hang out with me in the hospital room to read the chart and provide some continuity?

How much would it cost to have the chart transcribed in the early evening by some smart person in Bombay...with a useful summary and urgent watch issues?


Typical American response (although I'm not really familiar with non-American responses). First we label or name a problem, which then allows to believe we understand it fully. (I.e. Tired Resident Syndrome or some such) Then we implement a policy fix (shorten work hours) and assume we've fixed the problem.

Looks like both of these were wrong in this case. The problem Zion crusaded *wasn't* tired residents. It was more like improper triage and attention. The series of incidents that killed his daughter wasn't caused by tired or overworked residents, so the 'fix' hasn't really fixed much of anything and has introduced additional difficulties.

Thanks, Zion, thanks a lot. Zealotry is not really that useful a tool in 'fixing' problems because zealots have no real desire to understand a problem, they only want to impose their 'fix'. Just read Zion's story again in that light. He was out to punish residents and the health care system, not understand and improve it. Maybe he'll get lucky and end up with a relatively minor problem and be watched during the night by a first-year resident with an 80 patient load. Maybe he'll survive. Maybe.

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